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Study Design: A retrospective observational study of healthy volunteers and patients with degenerative and infectious endplate abnormalities in the lumbar spine., Objectives: Our purpose was to evaluate the usefulness of diffusion-weighted imaging (DWI) for the differentiation of degenerative and infectious endplate abnormalities using 1.5-T magnetic resonance imaging (MRI)., Summary of Background Data: DWI can provide valuable structural information about tissues that may be useful for clinical applications in differentiation between degenerative and infectious endplate abnormalities., Methods: Sixteen consecutive patients with endplate abnormalities that was detected by MRI of the lumbar spine, and 15 healthy volunteers were studied. DWI was performed using whole-body imaging with background body signal suppression with a b value of 1000 s/mm2. Apparent diffusion coefficient values of normal and abnormal vertebral bone marrow were calculated., Results: Twenty-nine vertebral abnormalities were found in 16 patients. Nine vertebral abnormalities in 5 patients were because of infections and 20 vertebral abnormalities in 11 patients were because of degenerative changes; 7 levels were classified as Modic type 1, 7 levels as type 2, and 6 levels as type 3. DWI showed hyperintensity in all patients with infection, similar to that used in positron emission tomography, but not in the intervertebral spaces of any patients with degenerative disease. Apparent diffusion coefficient values of infectious bone marrow were significantly higher than normal and degenerative bone marrow., Conclusion: DWI is useful for differentiation of degenerative and infectious endplate abnormalities. Moreover, MRI is widely used clinically because of the lack of ionizing radiation, low cost, and fast imaging time as compared with positron emission tomography. Therefore, DWI has the potential to be used as a screening tool.

Granulicatella adiacens is a nutritionally variant streptococci. Only 3 cases of vertebral osteomyelitis due to these microorganisms have been reported. We experienced a 73-year-old male who consulted us due to fever and back pain of about 1-month duration. On examination, a presystolic murmur was heard in the apical region. Echocardiography showed prolapse of the mitral valve, but no vegetation was observed. MRI revealed osteomyelitis of lumbar vertebrae. As G. adiacens was detected in blood culture, it was determined as the cause of vertebral osteomyelitis, and combination antibiotics therapy was started. The condition improved, the patient underwent valvoplasty, and no trace of infective endocarditis was noted in the resected valve. All the previous cases had infection caused by G. adiacens and complicated with infective endocarditis. This is the first case without infective endocarditis. Vertebral osteomyelitis due to NVS is very rare. Since nutritionally variant streptococci do not grow in common culture media, and since the sensitivity of isolation by standard conventional biochemical methods is low, the condition may be misdiagnosed as blood-culture-negative vertebral osteomyelitis. Therefore, the possibility of nutritionally variant streptococci infection should be considered if a patient with vertebral osteomyelitis shows a positive Gram stain but negative blood cultures.

Study Design: Case report., Objective: To illustrate the usefulness of broad-range bacterial polymerase-chain-reaction (PCR) testing in osteoarticular infections by Capnocytophaga canimorsus., Summary of Background Data: C. canimorsus is a gram-negative bacillus that was first identified in 1976. It is a normal inhabitant of the oral mucosa of dogs (26%) and cats (15%). The main clinical patterns are septicemia, which may cause fatal septic shock (in 30% of cases) but arthritis and discitis are possible. C. canimorsus is susceptible to many antimicrobials including β-lactam antibiotics., Methods: About a case report of 54-year-old man transferred to our institution for discitis, we discuss about PCR for C. canimorsus discitis diagnosis., Results: At admission, the only abnormal physical finding was global pain and stiffness of the lumbar spine. Radiographs of the lumbar spine and pelvis showed lumbar spondylosis, degenerative disc disease, and previously known degenerative facet joint disease. Magnetic resonance imaging indicated L3-L4 discitis with damage to both vertebrae and adjacent discs. Findings were negative from blood and urine cultures, serological tests for the HIV and brucellosis, and sputum tests for Mycobacterium tuberculosis. A percutaneous biopsy of the L3-L4 disc was performed but the bacteriological studies recovered no organisms. A second needle biopsy was performed for broad-range 16S rDNA PCR testing, which identified C. canimorsus., Conclusion: Broad-range PCR provided the microbiological diagnosis of culture-negative discitis in our patient. Broad-range PCR should be considered in patients with culture-negative osteoarticular infections.

Study Design: Case-control study for assessing a diagnostic test., Objective: The aim of this study was to analyze the diagnostic yield of a multiplex real-time polymerase chain reaction (PCR) assay in the differential diagnosis of tuberculous vertebral osteomyelitis (TVO) and brucellar vertebral osteomyelitis (BVO)., Summary of Background Data: Vertebral osteomyelitis (VO) is one of commonest osteoarticular complications of tuberculosis and brucellosis. However, the very similar clinical, radiologic, and histologic characteristics of these entities mean that diagnosis requires etiological confirmation, but conventional microbiologic methods have important limitations., Methods: Fifteen vertebral samples from patients with TVO or BVO and 9 from pyogenic and nontuberculous mycobacteria VO were studied by multiplex PCR and conventional microbiologic techniques. To identify Brucella DNA, we used a fragment of 207 bp from the conserved region of the gene coding for an immunogenic membrane protein of 31 kDa of B. abortus (BCSP31) and for Mycobacterium tuberculosis complex, a fragment of 164 bp from the intergenic region SenX3-RegX3., Results: The histopathologic findings were inconclusive in 4 of 14 cases (28.6%) with TVO or BVO and cultures were positive in 11 of 15 cases (73.3%). Multiplex PCR correctly identified 14 of the 15 samples from patients with TVO and BVO and was negative in all the control samples. Thus, the overall sensitivity and specificity of the multiplex PCR were 93.3% and 90%, respectively, with an accuracy of 92% (95% CI, 81.4%-100%)., Conclusion: These results suggest that multiplex real-time PCR is far more sensitive than conventional cultures, and this, together with its speed, makes this technique a very practical approach for the differential diagnosis between TVO and BVO.

The goal of this study was to determine the efficacy and feasibility of surgical management of advanced thoracolumbar spine tuberculosis with kyphosis in children in poor general condition with 1-stage posterior decompression, interbody grafts, and posterior instrumentation and fusion. Between 2006 and 2008, 7 children with advanced thoracolumbar spinal tuberculosis accompanied by kyphosis and in poor general condition were treated with 1-stage posterior decompression, interbody grafts, and posterior instrumentation and fusion followed by chemotherapy. Mean follow-up was 34 months (range, 27-42 months). Patients were evaluated pre- and postoperatively for erythrocyte sedimentation rate (ESR), neurological status, pain, spinal canal compromise, and kyphotic angle. Spinal tuberculosis was completely cured and the grafted bones fused in all 7 patients. There was no recurrence of the disease in any patient at final follow-up. In all patients, ESR was normal within 3 months, Frankel neurological classification improved, and pain relief was obtained. Average canal compromise was 52.57% (range, 35%-75%) preoperatively and 9.86% (range, 0%-19%) postoperatively. Average preoperative kyphosis was 37.9°, which decreased to 5.4° postoperatively. There was no significant loss of correction at last follow-up. Our results show that 1-stage posterior decompression, interbody grafts, and posterior instrumentation and fusion followed by chemotherapy is an alternative treatment for children with advanced thoracolumbar spinal tuberculosis and in poor general condition., (Copyright 2010, SLACK Incorporated.)

Psoas abscess following spine surgery is a rare condition that can be overlooked or delayed as a result of its vague clinical manifestations. Gone unchecked, it can lead to severe morbidity and even death. We present a 71-year-old female patient who developed bilateral psoas abscess immediately following L2 through S1 posterior instrumented fusion. The patient underwent CT-guided percutaneous drainage of the bilateral psoas abscess and blood cultures revealed methicillin-resistant Staphylococcus aureus (MRSA) sensitive to vancomycin. Following surgical re-exploration, debridement and removal of part of the instrumentation, the patient received antibiotic treatment for 12 weeks and at 1-year follow-up the patient continues asymptomatic., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Study Design: Case series., Objective: To improve the isolation rate for pyogenic spondylodiscitis, we developed a new needle biopsy technique., Summary of Background Data: The biggest problem in treating lumbar pyogenic spondylodiscitis is a low success rate in isolating a causative microorganism. The rates have been reported 42% to 64%., Methods: There are 3 steps: (A) Insert a 21-G needle as for discography, aspirate pus or fluid as specimen. (B) If step A fails, inject saline and collect fluid as reflux. (C) If step B fails, insert another needle into the disc, inject saline and collect reflux from the other needle. We applied this approach to 12 patients with a mean age of 64.3 years., Results: We were able to collect fluid samples in all cases and the culture was positive in 11 cases (91.6%). Staphylococcus aureus was the most frequently identified organism (41.7%)., Conclusion: This simple method improved the isolation rate and should improve the treatment of lumbar pyogenic spondylodiscitis.

The authors present a case of a patient with sickle-β thalassaemia (Sβ(0) Thal) who had bilateral psoas abscesses on a background of splenectomy in early childhood. The patient also turned out to have vertebral osteomyelitis and hydronephrosis on the side of the larger abscess. The only organism recovered from the patient was a Bacteroides species. The patient was managed with percutaneous drainage and intravenous antibiotics and made a full recovery.

Brucellosis is an infectious disease spread by consumption of non-pasteurized milk products or through contact with infected animals. Spinal involvement is one of the most important complications and the lumbar area is the most frequently affected site. Among the neurological consequences, nerve root compression can be a result of epidural abscess, granuloma or discitis secondary to vertebral body involvement. In this case report we present a 50-year-old male patient with brucellar discitis without spondylitis which caused lumbar disc herniation. We want to emphasize that discitis should also be considered in differential diagnosis of nerve root compression in suspected cases.

We describe a rare case of surgical treatment for a repeated contained rupture of an infected abdominal aortic aneurysm (AAA) with concomitant vertebral erosion. A 59-year-old man presented to a nearby hospital with abdominal pain and fever. On admission, computed tomography (CT) scan revealed a contained rupture of AAA, but the patient declined the offer of surgical therapy. Thereafter, the retroperitoneal hematoma gradually reduced in size. The third and fourth lumbar vertebrae were eroded on the CT scan 12 months after the appearance of the first symptom. However, 21 months after the first symptom, he suffered severe lumbago and was diagnosed with recurrence of contained AAA rupture and vertebral body destruction. He underwent debridement of eroded vertebrae and in situ graft replacement of AAA with omentum flap wrapping. Intraoperative microscopic examination of the hematoma revealed gram-positive Streptococcus. His postoperative course was uneventful, and CT 12 months after surgery did not reveal further deterioration of vertebral erosion or fluid accumulation. Repetitive contained AAA rupture may be another entity in contrast to chronic contained AAA rupture. Vertebral erosion could be associated with infection rather than mass effects of the contained hematoma. Surgical treatment is indicated to prevent life-threatening re-rupture and severe spinal instability., (Copyright 2010 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Late post-diskectomy tuberculous spondylodiskitis at the operated level is an extremely rare phenomenon. We describe a unique case of a same level tuberculous spondylodiskitis with pus drainage from the operative scar 8 years after simple L4/L5 diskectomy and review the relevant literature. The therapeutic management and possible pathogenic mechanisms are discussed as well.

Objective: To explore the surgical measurements and principles in the treatment of thoracic and thoracolumbar spinal tuberculosis., Methods: From 2001 to 2008, 232 cases of thoracic or thoracolumbar spinal tuberculosis were treated by operations in the study, including 148 males and 84 females with an average age of 37.8 years ranging from 20 to 76 years. Preoperative assessment displayed as follow: Cobb angles of kyphosis < 30 degrees in 65 cases, 30 degrees to 60 degrees in 147 cases, > 60 degrees in 20 cases; Frankel B grade in 13 cases, C in 12 cases, D in 41 cases, E in 166 cases. Among them, 48 cases were performed with one-stage transpedicular screw system and anterolateral debridement by single incision, 184 cases with one-stage anterior approach (debridement, fusion, and plate-screw fixation) routinely. The tissues and liquor puris debrided from focus were sent for pathological examination, Bacillus tuberculosis detection and culture, and drug sensitivity test. The patients were given anti-tuberculosis therapy according the results of drug sensitivity test for 1 to 1.5 years. The followed-up included relapse rate, fusion of the bone graft, the status of neurological restoring, kyphosis correction etc., Results: All 232 cases recovered from perioperation and 230 cases got primary wound healing, only 2 cases performed with single incision one-stage posterior instrumentation and anterolateral debridement got complications of wound healing problems and the sinus formation,which delayed healed by changing dressings. The complications included intercostals neuralgia in 135 cases and pneumothorax or hydrothorax in 13 cases, which needed not special handling. All the patients in this series got the followed-up ranging from 1.0 to 4.5 years (means 2.6 years). No recurrence within followed-up period and bone union was found in all cases. All 66 cases with the neurological deficits recovered partially or totally. Kyphosis correction were achieved by 27.5 degrees on average postoperatively and showed a mild loss of 4.2 degrees on average during followed-up period. All cases were confirmed with Bacillus tuberculosis infection by pathology. Bacillus tuberculosis was detected and culture successfully in 107 cases (46.1%), 40 strains (37.4%) were drug resistant and in which 8 strains (7.5%) were multi-drug resistant., Conclusion: For the treatment of thoracic and thoracolumbar spinal tuberculosis, the best treatment include directional chemotherapy, one-stage anterior approach with thorough debridement, auto-rib or Ti-mesh fusion, and plate-screw fixation.

The relationship of Modic change to pain and inflammation remains to be unclear. Recently, some authors have reported that Modic type 1 signals are closely related to infection. However, if the patients do not have severe back pain, fever, or an abnormal blood profile, it is difficult to distinguish between common Modic change and infection. The purpose of this study was to examine the prevalence of pyogenic spondylitis in patients who showed Modic type 1 change without other signs of infection. Seventy-one patients with Modic type 1 change were evaluated (average age 55, 32 males and 39 females). X-ray and magnetic resonance imaging (MRI) were performed to investigate low-back pain and leg pain. Body temperature was measured and blood analysis (including white blood cell count and level of C-reactive protein) was conducted for all patents. All 71 patients with Modic type 1 change, but without other signs of infection were followed for 2 years. Low-back pain, X-ray, and blood analyses were performed every 3 months; and MRI was performed every year. Severe low-back pain or abnormal signs developed in four patients during the follow-up. Pyogenic spondylitis was diagnosed in three patients by symptoms, blood results, and imaging, and confirmed by biopsy. Two of the three patients were diabetic. A total of 4.2% of patients with Modic type 1 change, but without other signs of infection were diagnosed as having pyogenic spondylitis during the 2-year follow-up, therefore, it is important to consider this before treating Modic type 1 change.

Tuberculosis is a common disease worldwide. However, it now is clear that tuberculosis can affect the kidney more insidiously. We describe a case of lumbar tuberculosis associated with simultaneous membranous nephropathy and interstitial nephritis, in which recovery of renal function occurred after treatment with steroids in addition to antituberculosis agents.

Study Design: Case report., Objective: To report a patient with spinal tuberculosis (TB) and paravertebral abscess formation after kyphoplasty of L1. The literature is reviewed, and diagnostic options are discussed., Summary of Background Data: Kyphoplasty is a well-established procedure in the treatment of osteoporotic compression fractures and metastatic tumors of the vertebrae. Although complication rates are low, there is evidence for an increased risk of serious local infections after kyphoplasty in patients with any history of systemic infection. Spinal TB accounts for 2% of all TB cases with a trend toward an increased incidence in parallel with the growing number of immunocompromised patients. To our knowledge, only 1 article had reported a patient suffering from Pott disease after vertebroplasty., Methods: A 70-year-old patient with compression fracture of L1 underwent percutaneous kyphoplasty using polymethyl methacrylate., Results: Two weeks after kyphoplasty, the patient was readmitted with backache and signs of acute infection. Magnetic resonance imaging confirmed the diagnosis of spondylitis with paravertebral abscess formation. A tissue specimen obtained by computed tomography-guided percutaneous biopsy did not yield any pathogen. As broad-spectrum antibiotic therapy failed, combined surgery consisting of posterior instrumentation of Th11-L3 and anterior debridement, corporectomy of L1, and interposition of a titanium mesh cage filled with autologous rib graft was performed. Histologic examination of resected tissue and PCR and culture results confirmed diagnosis of spinal TB. Despite adequate antibiotic treatment and local surgical interventions, the patient died from septic multiple organ failure., Conclusion: Indication for kyphoplasty in patients with any history of local or systemic infection should be scrutinized rigorously. Symptoms of spinal TB are often nonspecific, and the clinician should be aware of this entity. Active investigation including microbiological and histologic examination is of utmost importance to avoid any delay in correct diagnosis and specific treatment.

Here presented is an extremely rare case of a spinal osteomyelitis (L5-S1) with epidural empyema in a non-immunocompromised 62-year-old man caused by Yersinia enterocolitica O:9. The infection occurred acutely and required immediate surgical treatment. Y. enterocolitica was cultured from the empyema fluid, wound swabs of the intervertebral disc L5-S1 and stool cultures. Following the surgical decompression and antibiotic treatment, the patient recovered completely, without neurological deficits. A review of the literature revealed only sparse cases of spondylodiscitis due to other Y. enterocolitica serogroups. To our knowledge, we report here the first case of a spondylodiscitis of the lumbar spine caused by Y. enterocolitica serovar O:9 in a non-immunocompromised patient.

We report a culture-proven case of Mycobacterium bovis discitis in a 67-year-old man who had received intravesical Bacillus Calmette-Guérin for bladder cancer 5 years previously. He presented with severe low back pain, and imaging revealed features of discitis and paraspinal abscesses. On aspiration of the abnormal tissue, culture confirmed infection with M. bovis. Quadruple antituberculous therapy was commenced at this stage, with a subsequent good clinical response. Hematogenous spread of M. bovis is a rare, often delayed, complication of intravesical BCG therapy, but early appropriate treatment can result in a good prognosis.

Study Design: A case report of spontaneous pyogenic spondylodiscitis and epidural abscess in vertebral fracture by an uncommon pathogen is described., Objective: The uncommon presentation of spondylodiscitis with epidural abscess due to Gemella morbillorum after an acute lumbar vertebral fracture treated conservatively is discussed., Summary of Background Data: Spontaneous spondylodiscitis and epidural abscess in nonsurgical fractures is exceptionally rare. To date its colonization with Gemella morbillorum is not described in the literature. Its resistance to penicillin is also uncommon., Methods: Diagnosis was based on clinical history, hemocultures, samples from CT-scan guided punction and, supported by magnetic resonance imaging., Results: Clinical and radiologic improvement were observed after treatment based on a combined specific antimicrobial therapy and surgical drainage of epidural abscess., Conclusion: Spondylodiscitis and epidural abscess secondary to an acute nonsurgical vertebral fracture are rare manifestations. Microbiology and MRI are vital components in diagnosis. An emergency decompression and appropriate antibiotic regimen is the solution for a favorable outcome.

Introduction: Multilevel discitis is rare, and classically due to granulomatous organisms like Mycobacterium tuberculosis, brucella and fungal species., Conclusion: We report a case of non-contiguous multilevel synchronous bacterial discitis involving cervical, thoracic and lumbar discs, attributable to Staphylococcus aureus.

Background Context: Posterior element tuberculosis is rare accounting for only 3% to 5% of all spinal tuberculosis. To our knowledge, no case of isolated facet joint tuberculosis with coronal decompensation has been reported in literature so far., Purpose: The purpose of this study was to describe a case of tuberculous arthritis of the lumbar facet joint and its effect on coronal balance of the spine., Study Design: The study design was a case report., Methods: A 14-year-old boy presented with a 3-month history of back pain without radiation and with normal neurological findings. Computed tomography and magnetic resonance imaging showed destruction of the right L4-L5 facet joint with L5-S1 spondylolytic listhesis. Despite 2 months of antitubercular medication after a core biopsy confirmation of L4-L5 facet tuberculosis, there was progression of coronal decompensation of the spine with severe pain. Instrumentation with intertransverse fusion was done as a secondary procedure., Results: The patient was completely relieved of symptoms after instrumented fusion along with antitubercular medication., Conclusion: Isolated lumbar facet joint tuberculosis is a rare entity with a potential for coronal decompensation of the spine, which makes early instrumented fusion with antitubercular medication a viable treatment modality., (Copyright 2010 Elsevier Inc. All rights reserved.)

Tumour necrosis factor-alpha (TNF-α) inhibitors represent an important treatment advance for a number of inflammatory conditions, including inflammatory bowel disease. Since their introduction in 1999, it has become clear that some biological therapies may be associated with an increased risk for bacterial infections. Herein we present the first case of septic arthritis and spine empyema, caused by S. aureus, in a 63 year-old patient with ulcerative colitis, who was under treatment with Infliximab and with 40mg per day of prednisolone., (Copyright © 2009 European Crohn's and Colitis Organisation. All rights reserved.)

Background: Textbooks describe hematogenous discitis in adults as starting in the anterior vertebral body near the endplates., Case Report: Hematogenous Staphylococcus aureus discitis developed at L1-L2 in an 81-year-old woman. On the first magnetic resonance imaging (MRI) scan performed 4 days after symptom onset, the only abnormalities were high signal from the disk on T2-weighted images, gadolinium enhancement of the soft tissues anterior to L1-L2, and epidural involvement. The endplates and vertebral bodies were normal. A subsequent MRI scan showed features typical of infectious discitis., Discussion: We found a single similar case report in the medical literature, indicating that discitis starting outside the anterior vertebral body is rare. Nevertheless, an increasing number of similar cases may be diagnosed in the future, as MRI is being performed increasingly early in patients with a clinical suspicion of infectious discitis., Conclusion: Hematogenous infectious discitis in adults may start in some patients within the disk, soft tissues anterior to the disk, or epidural space. To avoid diagnostic and therapeutic delays, physicians should be aware of this unusual presentation of infectious discitis on very early MRI scans. When the clinical picture suggests discitis and findings from the early MRI scan are atypical, a repeat MRI scan should be obtained 1 week later to confirm the diagnosis., (Copyright 2009 Société française de rhumatologie. Published by Elsevier SAS. All rights reserved.)

A 69-year-old man presented with subarachnoid hemorrhage due to a ruptured anterior communicating artery aneurysm. The aneurysm neck was clipped and a lumbar drainage tube was inserted for cerebrospinal fluid drainage. However, the tube was accidentally cut during removal and a fragment remained in the spinal canal. A subarachnoid, subcutaneous abscess appeared 7 days later, which was treated with antibiotics. He noted numbness of his left leg after 6 months, and gait disturbance manifested 3 months later. T(1)-weighted magnetic resonance (MR) imaging disclosed a well-enhanced extramedullary mass at the T9-10 intervertebral level, and T(2)-weighted MR imaging showed moderate edema around the peri-lesional spinal cord. The mass containing a drainage tube fragment was surgically removed. Histological examination confirmed granuloma due to chronic infection. This case suggests that retained tube fragments should be removed surgically, especially in the presence of infectious complications.

Anaerobic organisms are a rare cause of spondylodiscitis. Eggerthella lenta is an organism that is not commonly associated with spondylodiscitis. We describe a case of spondylodiscitis due to Eggerthella lenta in an 82-year-old Chinese woman presenting with back pain. The organism was isolated from tissue cultures obtained via radiology-guided biopsy.

A 61-year-old male patient with microbiological diagnosis of L3-L4 spondylodiscitis and persist pain underwent a (67)Ga scintigraphic study to assess the antibiotic treatment response. Pathological uptake foci in vertebral bodies of L2 and L4 were observed in the (67)Ga planar scintigraphy. A SPECT low-dose CT of the lumbar spine was performed as part of anatomical correlated protocol, detecting an active spondylodiscitis in L3-L4 and a second uptake foci in L2 that was identify as a Schmorl's node. In this case the SPECT-CT hybrid image allowed us to avoid a false positive diagnosis to by locate and characterize an image with abnormal uptake of (67)Ga, improving the test specificity and avoiding a wrong diagnosis.

Background: Although spondylodiscitis is rare, it is increasingly described in patients with compromised immunity due to malignancy, chemotherapy or immunosuppression. Typical pathogens are staphylococcus aureus and enterobacteria; fungal spondylodiscitis is uncommon., Case Report: We present a case of aspergillus spondylodiscitis following pulmonary aspergillosis in a patient with multivisceral and kidney transplantation. Due to irreversible disc destruction, surgical restoration by autologous iliac crest graft was required in addition to intravenous antifungal therapy, which consisted of voriconazole, caspofungin and liposomal amphotericin B., Conclusions: Aspergillus spondylodiscitis is a diagnostic and therapeutic challenge, a combination of surgical debridement and antifungal therapy is inevitable to prevent rapid progression of invasive aspergillosis and neurological damage.

Study Design: Thirty-four patients having advanced spinal tuberculosis with angulated kyphotic deformity who underwent posterior en bloc spondylectomy were reviewed., Objective: To evaluate clinical outcomes of posterior en bloc spondylectomy in patients having spinal tuberculosis with angulated kyphotic deformity., Summary of Background Data: Spinal tuberculosis may be associated with angulated kyphotic deformity. The conventional treatment for angular kyphosis is combined anterior and posterior decompression, fusion, and stabilization., Methods: From 1998 to 2005, 34 patients (mean age, 25.1 years) underwent posterior 1-stage en bloc spondylectomy. The level of tuberculosis and kyphosis was T9 in 2 patients, T10 in 5, T11 in 13, T12 in 14, and L1 in 12. The anterior column with tuberculosis present was completely removed by en bloc spondylectomy. Strut autograft was used to restore anterior column stability. Posterior pedicle screw fixation and fusion were typically performed. RESULTS.: No perioperative mortality occurred in these patients. At follow-up, according to Odom's classification, the excellent outcome was seen in 9 patients, good in 23, fair in 1, and poor in 1. The kyphotic Cobb angle improved from the preoperative average of 57.8 degrees to a postoperative average of 11.4 degrees. The average horizontal distance between C7 and S1 was 13.9 mm before surgery and 3.9 mm after surgery. Seventeen patients showed a postoperative improvement in American Spinal Injury Association grade after the operation. The perioperation complication occurred in 3 of the 34 cases. Two patients had evidence of screw loosening at follow-up. Ten patients had questionable fusion or pseudarthrosis., Conclusion: The purpose of this article is more to describe the technique of posterior en bloc spondylectomy in patients with spine tuberculosis with kyphotic deformity. From the results of this preliminary study, en bloc spondylectomy for the treatment of spinal tuberculosis with angulated kyphotic deformity can be a safe and effective technique.

We discuss an elderly male who developed severe back pain, rapidly progressing paraparesis and urinary retention consequent to L5-S1 spinal tuberculosis with dissemination of epidural tubercular abscess and granulation tissue to the cervical, thoracic, lumbar and sacral region. The initial diagnosis of lumbo-sacral pathology with high thoracic extension was tackled by an L5 laminectomy and decompression along with saline flushing and evacuation of the thoraco-lumbar and sacral epidural abscess with the aid of a catheter passed superiorly and inferiorly. He developed neck pain and upper limb weakness subsequently and was found to have extensive extradural cervical compression by granulation tissue. He underwent C4-7 laminectomy and decompression of the cord. He was started on four-drug anti-tubercular treatment. At 6-month follow-up, he had marked neurological improvement. MRI screening of the entire spine showed complete resolution of the disease. Contiguous epidural involvement of the entire spine by tubercular pathology has never been reported before. We suggest that screening of the entire spine should be considered in select cases of spinal tuberculosis based on symptomatology.

Objectives: Vertebral osteomyelitis is a cause of back pain that can lead to neurologic deficits if not diagnosed in time and effectively treated. The objective of this study was to systematically review the clinical characteristics of pyogenic vertebral osteomyelitis (PVO)., Methods: The authors conducted a systematic review of the English literature. The inclusion criteria included studies with 10 or more subjects diagnosed with PVO based on the combination of clinical presentation with either a definitive bacteriologic diagnosis or pathological and/or imaging studies., Results: The 14 studies that met selection criteria included 1008 patients with PVO. Of them, the majority (62%) were men, with back pain and fever as the most common presenting symptoms. Diabetes mellitus was the most common underlying medical illness, while the urinary tract was the commonest source of infection. Staphylococcus aureus was the most commonly isolated organism. Computed tomographic guided or open biopsy yielded the causative organism more often than blood cultures (77% versus 58%). Plain radiography showed abnormalities in 89% of the cases, while bone scanning and computed tomography or magnetic resonance imaging were positive in 94% of the cases, revealing lumbar as the most commonly affected area. The attributable mortality was 6%, while relapses and neurological deficits were described in the 32% and 32% of the cases, respectively., Conclusion: PVO is an illness of middle-aged individuals with underlying medical illnesses. Although the mortality rate is low, relapses and neurological deficits are common, making early diagnosis a major challenge for the physician.

The study includes a case report and a literature review. The main objective of this study is to present a case of spondylodiscitis due to a fungal pathogen, Blastoschizomyces capitatus and to review the published literature on this emergent fungus in etiology of spondylodiscitis, and osteomyelitis. Osteoarticular involvement due to B. capitatus has been reported in six cases, and vertebral involvement has been seen in five of them. All of these cases had underlying malignancy. Infection is usually advanced at presentation. Case notes and online databases were reviewed. Organism was isolated from bone material in all of the cases and antibiotic treatment by antifungal agents cured the infection. We present another case of infectious spondylodiscitis due to B. capitaus, which is reported first in Turkey and tried to attract attendance to this emergent fungal pathogen as an etiologic agent of spine infections in cancer patients.

Proteus organisms are rare causes of osteomyelitis. Vertebral osteomyelitis caused by this organism has only been reported in 21 cases over the last 75 years. Although Staphylococcus aureus is the most common cause of vertebral osteomyelitis, rare causes such as P. mirabilis may need to be considered in the context of recent urinary tract infection or urological surgery. Therefore biopsy should be undertaken to establish the causative organism and determine appropriate antibiotic susceptibility.

We report a patient who presented with inflammatory back pain due to multisegmental spondylitis. Following a vertebral biopsy which failed to detect an infectious organism, the patient was treated with etanercept, a tumor necrosis factor (TNF)-alpha inhibitor, for suspected undifferentiated spondyloarthritis. The back pain worsened and the spondylitic lesions increased. Only in a vertebral rebiopsy with polymerase chain reaction (PCR) amplification of Tropheryma whipplei, the causative agent of Whipple's disease was identified. Tropheryma whipplei should be considered as a cause of spondylitis even with multisegmental involvement and in the absence of gastrointestinal symptoms. In this clinical setting, routine PCR for Tropheryma whipplei from vertebral biopsies is recommended.

The objective of this study was to analyse the presentation, aetiology, conservative management, and outcome of non-tuberculous pyogenic spinal infection in adults. We performed a retrospective review of 56 patients (35 women and 21 men) of pyogenic spinal infection presenting over a 7-year period (1999-2006) to the Department of Spinal Surgery of Hesperia Hospital. The medical records, radiologic imaging, bacteriology results, treatment, and complications of all patients were reviewed. The mean age at presentation was 47.8 years (age range 35-72 years), the mean follow-up duration was 12.5 months. The most common site of infection was lumbar spine (n: 48), followed by the thoracic spine (n: 8). Most patients were symptomatic for between 4 and 10 weeks before presenting to hospital. The frequently isolated pathogen was Staphylococcus aureus in 31 of 56 cases (57.6%). Percutaneous biopsies were diagnostic in 57% of patients; the open biopsy was indicated if closed biopsy failed and when the infection was not accessible by percutaneous technique. The patients were managed by conservative measures alone, including antibiotic therapy and spinal bracing. The mean period of antibiotic therapy was 8.5 weeks (range 6-9 weeks), followed by oral antibiotics for 6 weeks. All patients had a supportive spinal brace for mean 8 weeks (range 6-10 weeks). The duration of the administration of oral antibiotics was dependent on clinical and laboratory evidence (white cell count, erythrocyte sedimentation rate, C-reactive protein) that the infection was resolved. The follow-up MR gadolinium scans were essential to monitor the response to medical treatment. The diagnosis of pyogenic spinal infection should be considered in any patient presenting with severe localised unremitting back and neck pain, especially when accompanied with systemic features, such as fever and weight loss and in the presence of elevated inflammatory markers. The conservative management of infection with antibiotic therapy and spinal bracing was very successful.

Background: Recent studies suggest an association between sciatica and Propionibacterium acnes. "Modic type I changes" in the vertebrae are closely associated with sciatica and lower back pain, and recent studies have questioned the ability of conventional magnetic resonance imaging (MRI) to differentiate between degenerative Modic type I changes and vertebral abnormalities caused by infection., Purpose: To test whether bacteria could be cultured from biopsies of Modic type I changes., Material and Methods: Twenty-four consecutive patients with Modic type I changes in lumbar vertebrae had a biopsy taken from the affected vertebra by a strict aseptic procedure. The biopsy was split into two specimens, which were inoculated into thioglycolate agar tubes in the surgical theatre and transported to the microbiology laboratory. In the laboratory, one specimen was streaked onto plates and analyzed for anaerobic and aerobic culture. The other tube was left unopened and incubated directly. Plates and tubes were incubated for 2 weeks and observed for visible growth., Results: None of the biopsies yielded growth of anaerobic bacteria. In one patient, both biopsies yielded growth of Staphylococcus epidermidis, and in another patient coagulase-negative staphylococci were isolated from one biopsy. Both patients received oral antibiotics without convincing effect on symptoms., Conclusion: Our results showed no evidence of bacteria in vertebrae with Modic type I changes. The isolation of staphylococci from two patients probably represented contamination.

Contiguous arterial infections are extremely rare, and their actual rate of occurrence is not known. These infections occur as a result of direct invasion of an artery from an adjacent septic focus. Reaching the diagnosis of infected aorta is very difficult when there are contiguous infections from spondylitis or psoas abscess, because the clinical features are nonspecific. Although computed tomography is the most useful diagnostic tool in the detection of aortic infections, the most frequent findings mimic those of other diseases, such as retroperitoneal fibrosis, lymphoma, and periaortic lymphadenopathy. Diagnosis becomes even more challenging when an infected aorta is of normal diameter. Herein, we report the case of a 64-year-old man who experienced nonaneurysmal abdominal aortic rupture due to spondylitis and psoas abscess. Despite appropriate surgical management, the patient later died. We review the relevant medical literature and examine specific considerations that surround the diagnosis and treatment of this rare condition.

We report a case of spondylodiscitis caused by Staphylococcus aureus 8 months after laminectomy of the lumbar spine, occurring in a rheumatoid arthritis (RA) patient interruptedly treated with anti-tumor necrosis alpha (TNFalpha) agents. The patient had suffered from seropositive RA for 2 years. An intravenous infusion (200 mg) of infliximab, a chimeric antibody against human TNFalpha, was introduced; however, due to Pneumocystis jiroveci pneumonia, this therapy was withdrawn. Four months later, the patient underwent an L3-L4 and L4-L5 laminectomy for spinal stenosis. Two months after surgery, we started treatment with 25 mg of etanercept, a soluble humanized TNF receptor dimer, subcutaneously twice a week. At that time, wound healing was satisfactory and no evidence of infection was obtained. Eight months after surgery, septic spondylodiscitis of the lumbar spine occurred. To the best of our knowledge, this is the first case in the literature to show a delayed type of postoperative infection as a complication of non-instrumented orthopedic surgical procedures. Despite interruption of anti-TNFalpha therapy before surgery, patients may remain at risk of developing postoperative infections.

Study Design: A case report and clinical discussion., Objective: To discuss the diagnosis and treatment of Blastomyces dermatitidis in the spine., Summary of Background Data: Blastomycosis, like other fungal organisms, has a nonspecific appearance on radiographs, and is often mistaken for TB or a neoplasm. Nonsurgical treatment of this infection is possible, however, as seen in this case. The difficulty in diagnosing fungal infections often leads to a delay in treatment., Methods: We report on a 37-year-old Arabian woman who presented initially with progressive low back and anterior thigh pain without precipitating trauma. She was found to have 2 draining fistulas. Computed tomography-guided percutaneous drainage of the paravertebral phlegmon yielded purulent material that was pan cultured. The KOH preparation was consistent with a fungal pathogen, which was later identified as Blastomyces dermatitidis by polymerase chain reaction., Results: Radiologic studies of the lumbar spine and sacrum performed revealed extensive involvements with osseous destruction of L2-S1. The destruction was most severe at L3 with mild boney retropulsion at that level. Throughout the patient's treatment course, she complained of mild-to-moderate lower back pain and had no neurologic symptoms. Therefore, surgery was deferred., Conclusion: There are no pathognomonic findings of blastomycosis on magnetic resonance imaging. Fungal osteomyelitis is rarely identified in this country, and blastomycosis is even less often diagnosed. This case illustrates that fungal osteomyelitis should be considered in the radiographic differential diagnosis until a definitive diagnosis is made through biopsy.

Abdominal sacrocolpopexy is a standard surgical technique to repair apical vaginal prolapse. When approached laparoscopically, a uterus-preserving technique was suggested as potentially favorable for avoiding mesh-related complications. A 52-year-old Caucasian woman came to the emergency department with right-sided low back pain and vaginal discharge more than 1 year after undergoing a laparoscopic, uterus-preserving, cervicosacropexy with Mersilene (Ethicon Inc., Somerville, NJ) mesh and permanent Gore-Tex (W.L. Gore and Associates, Inc., Flagstaff, AZ) suture. Lumbar spine magnetic resonance imaging revealed diskitis and an epidural abscess at the L5 to S1 vertebral levels, and a fistulous tract was identified extending from the rectovaginal space to the affected vertebrae. The patient underwent a fine-needle aspiration of the epidural abscess and intravenous antibiotic therapy was started. However, because of a lack of symptom resolution she was taken to the operating department on hospital day 11 and underwent a total abdominal hysterectomy, left salpingectomy, right salpingo-oophorectomy, bilateral ureterolysis, and excision of an infected Mersilene mesh. Surgical findings were notable for 2 pinpoint areas in the upper vagina consistent with fistulae tracts communicating with the retroperitoneal space. The patient recovered well from her surgery, and was discharged to a rehabilitation facility. Vertebral osteomyelitis, with or without an epidural abscess, is a rare complication of sacrocolpopexy. The findings of this case suggest this complication likely occurred as a result of a permanent suture being placed entirely (or nearly entirely) through the vaginal mucosa resulting in fistulae formation, bacterial seeding of the Mersilene mesh, and subsequent osteomyelitis. This highlights the importance of mesh and suture selection, and determining the most appropriate sites for mesh attachment.

This is a case report of acute L3/4 vertebral osteomyelitis due to Salmonella paratyphi A confirmed by culture from vertebral needle biopsy. From a review of the literature this is the first reported case with bacteriological confirmation. The rarity of Salmonella paratyphi spondylitis and the options for treatment are discussed.

Introduction: A combination of disk space narrowing and vacuum phenomenon on radiographs of the spine is usually considered a reliable indicator of degenerative disk disease. We report a case in which vacuum phenomenon was related to Clostridium perfringens discitis., Methods: A 79-year-old woman was admitted for inflammatory low back pain that had worsened steadily over the last 2 months. Her body temperature was normal, laboratory tests showed inflammation (erythrocyte sedimentation rate, 61 mm/h; and C-reactive protein, 13 mg/L), and blood cultures were negative. Imaging studies (radiographs, computed tomography [CT], and magnetic resonance imaging) indicated L4-L5 discitis. Vacuum phenomenon within the L4-L5 disk was seen on radiographs and CT scans. C. perfringens was recovered by fine-needle biopsy of the disk. Diverticular disease of the colon was the only identifiable portal of entry. Amoxicillin therapy ensured a full recovery., Discussion: C. perfringens discitis is rare, with only 7 published cases in humans. A gastrointestinal portal of entry was identified in 70% of cases. Radiographs or CT scans visualized vacuum phenomenon in 80% of cases. Positive blood cultures were noted in 75% of cases. The outcome was favorable with antibiotic therapy, even when a single-drug was used. The other characteristics of C. perfringens discitis were indistinguishable from those of discitis caused by the usual organisms., Conclusion: Presence of gas within the disk does not rule out infectious discitis and may indicate C. perfringens discitis.

Because of the increased incidence of tuberculosis (TB) in recent years, infective spondylitis is still a major problem in the world. In skeletal TB the spine is the most often involved and lumbosacral spine involvement is rare. Nowadays early diagnosis and new medical treatment can reduce the incidence of the serious skeletal sequelae and the number of surgery procedures in spinal TB. We present a case of TB spondylodiscitis characterized by a rapid and progressive clinical and radiological improvement after treatment with Neridronate and chemotherapic drugs. Our data suggest that in the treatment of the TB spondylodiscitis the combined use of these drugs is a good alternative to stimulate bone reparative process to the chemotherapy alone. To our knowledge this is first case of a patient with TB discitis treated with Neridronate. Further studies are necessary to confirm the effectiveness of Neridronate treatment added to antiTB drugs in spondylodiscitis.

Candidal vertebral osteomyelitis represents an extremely rare invasive mycosis and can be difficult to treat due to poor drug penetration into bony tissue. We report on a case of vertebral osteomyelitis caused by Candida krusei in a patient who had neutropenia as a result of chemotherapy for acute myelogenous leukaemia. The patient received prophylactic liposomal amphotericin B during chemotherapy but became febrile and experienced severe lumbar pain. Magnetic resonance imaging revealed vertebral osteochondrosis. C. krusei was recovered from blood cultures and voriconazole monotherapy was initiated but proved unsuccessful. The patient was then started on caspofungin monotherapy, which was discontinued after Candida krusei was no longer recoverable from blood cultures. However, as lumbar pain increased and spinal biopsy confirmed the presence of Candida krusei, caspofungin therapy was resumed. Oral posaconazole was added to the regimen when the patient did not improve after 30 days of caspofungin therapy. Combined antimycotic therapy resulted in a successful outcome.